Acute Frailty and Cross Boundary Care - Wirral’s Perspective

There has been a lot of excitement in the past few weeks with the release of the NHS Long Term Plan document and the Five Year Framework for GP Contract Reform.

The NHS Long Term Plan talked about alternatives to A&E admissions, increasing same day emergency care (SDEC) with the aim to increase zero day admissions, utilising community services, shared digital systems, enhanced care home schemes, boosting community integration and personalised care plans. So how does it apply to us?

We have our own Frailty Unit (called Older Persons Assessment Unit or OPAU) in Wirral University Teaching Hospital NHS Foundation Trust and we were part of the 2nd cohort of the Acute Frailty Network (AFN) in 2016. Following our participation in AFN, we have further embedded its recommended principles although it continues to be an ongoing challenge.

We have boosted our medical, nursing and therapy input into OPAU with enhanced consultant geriatrician cover to facilitate discharges. Our Specialist Nurses for Older People (SNOPs) who are present 8am – 8pm identify our frail patients, pull to OPAU and initiate Comprehensive Geriatric Assessment (CGA) early in their admission. They help avoid admission where appropriate and liaise with community teams for ongoing support by working very closely with our A&E department.

We strongly believe in admission avoidance where possible to reduce the risk of deconditioning of our frail patients. We have an ambulatory service for frail older people (Older Persons Rapid Assessment / Ambulatory Clinic or OPRA) where we will see patients at the brink of admission, with support of same day diagnostics and ensuring a management plan is in place, as well as liaising with our community teams for ongoing support including our Rapid Response Team and the Integrated Care Coordination Teams (ICCT).

The Nurse Practitioner for Older People (NPOPs) and Community Matrons who are part of ICCT provide invaluable input into these patients in the community. We have a Community Geriatrician Phone Line which GPs, community teams, etc. can ring for advice and signposting to services or can highlight patients at the brink of admission who may need OPRA review or a community visit.

As community geriatricians, we are an integral link between secondary care and the community. While the bulk of our work used to involve care home residents, following the roll out of Emergency Health Care Plans (EHCPs, where majority of the anticipatory clinical plans are documented) as well as the GP Enhanced Care Home Scheme, we now concentrate on the complex care home residents who require more specialist input. We have a robust system of sharing End of Life (EOL) information / EHCP locally as we know it is not just the plans, it is ensuring all involved in the residents’ care are aware of their wishes. EHCPs are well recognised in the Wirral now.

We have seen a reduction in care home admissions and death of care home residents in hospital in the past 12 months. This is particularly after the roll out of the Wirral’s Teletriage Service in June 2017, where our Teletriage nurses use iPads and Skype to assess patients, taking their EOL wishes into account if they are coded as EOL patients and then deciding on the appropriate response – advice or onward referral to own GP, GPOOH, district nurses, other community teams or if an ambulance is required, as well as highlighting high risk patients to the community geriatricians.

Due to the level of support into care home residents, we (community geriatricians) have seen a shift in our work to complex housebound patients, particularly severely frail patients with personalised care planning. Wirral CCG rolled out the Neighbourhood Programme in July 2018, where GP practices from a locality making up 9 neighbourhoods in the Wirral meet monthly to develop community integration, compare practices with the view to reduce variation and learn from each other. It has been a wonderful opportunity to raise awareness of frailty – identification beyond the electronic Frailty Index (eFI), care planning, increasing awareness of services in place which can support patients identified including the valuable and often untapped voluntary sectors.

We have seen initial anecdotal benefits of social prescribing over the past few months and look forward to its expansion, particularly amongst the high intensity users. It was an immensely proud moment to see a Frailty template created by a community matron and a GP through the Neighbourhood project with further input by ourselves to highlight those who are in the severely frail category. We are hoping this Frailty Template can be rolled out across our partner organisations to reduce duplication of assessments.

Wirral has been deemed to be one of the Global Digital Exemplar (GDE) sites working with Cerner. This will ultimately produce the Wirral Care Record which will allow staff in partner organisations to assess information in real time. It also creates multiple registries, importantly the Frailty Registry. Multiple domains of CGA of the severely frail patients identified will be pulled through to the Frailty Registry from the various systems of the different organisations highlighting what domains have been looked at and what is outstanding.

As a community geriatrician, this is certainly a very exciting time to be working with frail older people. Undoubtedly there is apprehension about the scale of the problem and questions about resources, but I do firmly believe that unless we know the scale of the problem down to the local level, it will be difficult to gauge the level of resources required. The NHS Long Term Plan will hopefully help address this and convince all that this is the right way forward!

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